Insurance has always been unclear when it comes to an understanding of what it covers and what it does not. In particular, many Medicare beneficiaries are still puzzled about how to navigate it. Featuring four parts and copayments, among others, it can be frustrating to attempt to steer through the details of what Medicare entails.
When it comes to cosmetic surgery and Medicare, the insurance coverage guidelines even become more blurry. Medicare does not cover purely elective cosmetic surgery. But, it does cover many popular and medically necessary cosmetic surgeries. These are surgeries that treat health problems while enhancing the patient’s appearance.
In this article, we will discuss Medicare’s cosmetic surgery rules. We will look at what it covers, what it does not, and the eligibility requirements you must meet before any procedure.
What is Medicare?
Generally, Medicare is an American federal health care insurance program that caters to the medical needs of 65 or older. It also caters to the medical needs of people under 65 and younger. It is also available to those diagnosed with End-Stage Renal Disease as well as other qualifying conditions. This insurance program was signed into law in 1965 by President Johnson to assist older Americans in paying for their medical expenses.
The Centers for Medicare and Medicaid Services (CMS) handles the management of this insurance program. It is also worth noting that it is partly funded by Medicare and social security taxes deducted from the income of its beneficiaries, the federal budget, and the premiums paid by those with Medicare pay.
Four different parts constitute Medicare. Beneficiaries must understand each piece and what it contains to decide when picking their preferred coverage. Its parts include:
• Part A: Hospital coverage, which includes inpatient stays at hospitals and skilled nursing facilities.
• Part B: Medical coverage, which includes outpatient services, doctor’s care, preventative care, and medical supplies.
• Part C: Medicare Advantage Plan. This is a health care service offered to employees of a private company that has a contract with Medicare to provide Part A and Part B Medicare benefits.
• Part D: Prescription Drug coverage program that was signed into law in 2003 by President George W. Bush
Each Medicare coverage part affects your out-of-pocket costs. There are some situations where it can serve as sole health insurance coverage. It can also act as a companion coverage to supplement additional insurance covers offered by an employer, former employer, or spouse. It is also crucial to note that Medicare does not cover all health care costs and other health care routines, like dental services.
When does Medicare cover cosmetic surgery?
Regarding Medicare coverage and cosmetic surgery, we have already mentioned that the program does not cover all cosmetic surgery procedures. It only covers medically required courses. These refer to those that are necessary after an accidental injury, breast cancer, or malformation. Upon admission for a covered cosmetic surgical procedure, you must pay Medicare Part A deductible of $1,216 before Medicare issues coverage for anything.
Once paid, Part A will cater for the total inpatient hospital amount for up to 60 days. Part B will cover 80% of the approved doctor’s charges and all outpatient fees not catered for by the hospital’s outpatient services. If the hospital’s outpatient department performs a covered procedure, the patient will have to pay a copayment besides the approved fees.
For Medicare to pay for the cosmetic procedure, it must be executed by a qualified health care practitioner who is part of Medicare. The process must also be medically necessary, meaning a licensed healthcare provider or physician must prescribe or order it. Medicare must also approve that the procedure is needed.
What type of cosmetic surgery procedures qualify for Medicare coverage?
If you are a Medicare beneficiary, three primary circumstances will qualify for Medicare coverage. They include:
1. Reconstruction surgery after trauma or injury
Bodily trauma or injury can result in severe damage to the bones, muscles, or skin. Extreme trauma and compound wounds, like those from burns and severe car accidents, are famous examples of injuries that need cosmetic surgery.
2.Repairing malformation to enhance body function
Various medical conditions, congenital disabilities, and aging can lead to somebody’s body lacking proper functioning. Developmental or genetic abnormalities often affect the formation of particular body parts.
Likewise, certain medical conditions can also cause a lack of function in specific parts and abnormal body structure. In some cases, cosmetic surgery can help enhance the overall functioning of such affected body parts. For instance, blepharoplasty, commonly known as eyelid surgery, is a cosmetic procedure covered by Medicare.
3. Breast Reduction or reconstruction surgery
After a breast cancer diagnosis and you choose to go through full or partial mastectomy, you are qualified for breast reconstruction surgery. This may involve using your body tissue in a procedure called tissue flap reconstruction. It can also take place using artificial implants in a process known as prosthetic reconstruction.
Medicare also covers breast reduction surgical procedures that meet their guidelines. In turn, Medicare will cover a reduction mammoplasty if there is at least one of the following in your medical documents:
• Notable arthritic effects in the cervical spine or upper thoracic
• Infection of the inframammary skin refractory or intertriginous maceration
• Symptomatic neck, back, or shoulder pain resulting from large breasts that do not improve within six months of treatment
• Permanent shoulder grooves with the presence of skin irritation resulting from bra straps and weight of the mammary glands
What does Medicare not cover?
If your cosmetic surgery is not medically necessary and is only for appearance, you will have to pay for 100% of the costs out-of-pocket. Examples of popular cosmetic surgery procedures that Medicare does not cover include:
• Breast augmentation that does not follow a mastectomy
• Tummy tuck
• Body contouring
• Breast lift
If there is a need for cosmetic surgery, your original Medicare plan will cover the cost or Medicare Advantage Plan. But, each of these plans has its distinct costs. In turn, it is crucial to ensure that you consult your doctor about any out-of-pocket expenses before undergoing any procedure